Program

Be Proud! Be Responsible!

Be Proud! Be Responsible! was developed to lower the prevalence of HIV/AIDS within inner-city, African American communities. The curriculum aims to help young people make “proud and responsible” decisions about their sexual behaviors.

This cognitive-behavioral program has repeatedly been shown to have an impact on participants’ knowledge of HIV/AIDS and on their attitudes and intentions regarding risky sexual behaviors (such as intentions to use condoms). Furthermore, the program has been shown to decrease sexual partners in adolescent males. Another study found that program participants reported less frequent unprotected sex and were less likely to engage in anal sex. An additional study found that the program increased positive attitudes towards abstinence and self-efficacy regarding the avoidance of unsafe or unwanted sex. Participants were also more likely to talk to parents about issues regarding sex then participants in the control group. In addition, another study found that participants were more likely to report consistent use of condoms. Frequency of intercourse has yielded mixed results, with one study reporting that the intervention lowered frequency of intercourse and another reporting that it did not. This program has not been found to have an impact on whether participants practice abstinence.

Be Proud! Be Responsible! has also been replicated with a diverse population in a suburban setting. Significant impacts were found in the areas of knowledge, efficacy, and intentions, but there was little change in sexual behavior. Additional analyses examining subgroup differences found a more consistent impact on students in suburban schools.

DESCRIPTION OF PROGRAM

Target population: Low-income, urban African American adolescents

The Be Proud! Be Responsible! program was designed to increase HIV/AIDS-related knowledge and weaken problematic attitudes toward risky sexual behavior within the inner-city, African American community. The curriculum consists of six culturally-appropriate, hour-long modules. These modules address facts, attitudes, and beliefs surrounding HIV and AIDS. They also teach condom use skills and negotiation-refusal techniques. The intervention is designed to be informative and entertaining and includes group discussion, games, mini-lectures, videos, condom demonstrations, role-plays, and other interactive activities.

Several modified versions of the Be Proud! Be Responsible! curriculum exist. Making Proud Choices! is a safer-sex-based extension and Making a Difference! is an abstinence-based extension. ¡Cuídate! is a culturally-tailored version for Latino adolescents. Be Proud! Be Responsible has also been replicated with a suburban population.

EVALUATION(S) OF PROGRAM

Note: The following studies evaluated early versions of the Be Proud! Be Responsible! program. When these studies were conducted, the curriculum was still in development and was not referred to by its current name. These summaries employ the current program name for purposes of clarity.

Evaluated population: In 1988, 157 black male adolescents (mean age=14.64) from Philadelphia, PA were recruited to participate in this study. Forty-four percent of participants were recruited from among outpatients at a local medical clinic, 32 percent were recruited from students attending assemblies at a local high school, and 24 percent were recruited at a local YMCA.

Approach: Participants completed baseline surveys on their recent sexual behavior. They also responded to questions about their attitudes and intentions regarding risky sexual behavior and their knowledge of AIDS and STDs. While they completed these measures, participants were stratified by age and then randomly assigned within age to either an AIDS-prevention intervention (n=85) or a career-opportunities intervention (n=72).

Participants assigned to the AIDS-prevention intervention were placed into small groups and received the entire “Be Proud! Be Responsible!” curriculum in a single, five-hour-long session. Participants assigned to the career-opportunities intervention also took part in a five-hour-long small group session, but their program dealt solely with career-related matters. All small group sessions were led by college-educated black adults.

Immediately following the intervention, participants were again surveyed on their attitudes and intentions regarding risky sexual behavior and on their knowledge of AIDS and STDs. Three months later, participants completed follow-up surveys.

Results: The Be Proud! Be Responsible! curriculum had an immediate positive impact on participants’ knowledge of AIDS and STDs and on their attitudes and intentions regarding risky sexual behaviors. The impact on knowledge and intentions remained significant at the three-month follow-up.

The curriculum also had an impact on participants’ sexual behaviors. Compared with participants who took part in the career-opportunities intervention, participants who received the Be Proud! Be Responsible! curriculum reported engaging in less risky sexual behavior during the three months immediately following the intervention. Though these adolescents were not significantly more likely to have practiced abstinence during those three months, they did report having had sex less frequently and with fewer women. They also reported fewer occasions of sex without a condom and were less likely to have had anal sex.

Evaluated population: In the late 1990s, 496 black adolescents (mean age=13.2) were recruited from public schools in Trenton, NJ to participate in this study.

Approach: Study participants completed baseline surveys on their recent sexual behavior. They also responded to questions about their attitudes and intentions regarding risky sexual behavior and their knowledge of AIDS and STDs. While they completed these measures, participants were stratified by age and gender, and then randomly assigned within age and gender to either an HIV risk-reduction intervention (n=269) or a general health promotion intervention (n=227). Participants were further assigned to a small group that was either homogeneous or heterogeneous in gender and led by either a male or female facilitator who was either Black or White. Facilitators all received eight hours of training.

Participants assigned to the HIV risk-reduction intervention received the entirety of the “Be Proud! Be Responsible!” curriculum in a single, five-hour-long session. Participants assigned to the general health promotion intervention also took part in a five-hour-long small group session, but their program dealt with non-sexual health concerns.

Immediately after the intervention, participants were again surveyed on their attitudes and intentions regarding risky sexual behavior and knowledge of AIDS and STDs. Ninety-three percent of participants completed follow-up surveys three months later and 93 percent completed a six-month follow-up

Results: The Be Proud! Be Responsible! Curriculum had an immediate positive impact on participants’ knowledge of HIV and their beliefs and intentions regarding condom use. This impact remained significant at the three-month and six-month follow-ups.

At the three-month follow-up, no significant behavioral differences were observed between the students who received the Be Proud! Be Responsible! curriculum and those who did not. At the six-month follow-up, however, significant differences emerged. Compared with participants who took part in the career-opportunities intervention, participants who received the Be Proud! Be Responsible! curriculum had engaged in less risky sexual behavior. Though these adolescents were not significantly more likely to have practiced abstinence during the previous three months, they reported having unprotected sex less frequently. They also reported having anal sex less frequently and with fewer partners.

The impact of the Be Proud! Be Responsible! curriculum was found to be unrelated to the race and gender of the facilitator, the gender of the participants, and the gender composition of the intervention group

Note: Though this study reviews implementations at five evaluation sites, only two of those sites instituted a random assignment design. Therefore, we will only summarize the evaluated population, approach, and results from the two sites that meet the appropriate experimental design standards.

Evaluated population: A total of680 adolescents across two evaluation sites served as the samples for this study (380 participants resided in Sacramento, California). Within this sample, 45 percent of participants were male. The race/ethnicity distribution was as follows: 25 percent White, 18 percent Black, 39 percent Hispanic, and 18 percent of other descent. The Nashville, Tennessee site provided 300 participants, 41 percent of whom were male. The race/ethnicity distribution at this site was as follows: .3 percent White, 77 percent Black, 17 percent Hispanic, and 5 percent of other descent.

Approach: Participants were randomly assigned to either the Be Proud! Be Responsible! HIV prevention workshop prior to the collection of their post-test data, or the wait-list control condition in which they would attend the Be Proud! Be Responsible! workshop following the collection of their post-test data.

The length of the intervention varied between five and nine hours, depending on the site.

Participants were administered a questionnaire addressing an array of sex constructs including: intentions to use condoms; attitudes towards condoms; self-efficacy regarding the avoidance of unsafe or unwanted sex; skills avoiding unwanted sexual interactions; sexual knowledge; abstinence beliefs, and attitudes; and the use of friends, parents, or sex partners as social support and knowledge resources.

Data were collected at three points in time for the intervention group: before participating in the workshop, immediately following the workshop, and at a one-month follow-up assessment. The wait-list control group provided data at two points in time: following the intervention group’s completion of the workshop, and at the one-month follow-up point.

Results: At the Sacramento site, the intervention group reported significantly greater intentions to use condoms than did the control group. The control and experimental group did not significantly differ on any other outcome measures. In Nashville, intervention participants were more likely to believe in and have positive attitudes towards abstinence, have higher levels of self-efficacy regarding the avoidance of unsafe or unwanted sex, and talk to parents about issues regarding sex. There were no significant differences between the control and experimental group on any other outcomes.

Evaluated population: 1357 9th and 10th grade students enrolled in mandatory health education classes from 2000 to 2002 at ten high schools in a midsize metropolitan area in the Midwest. Of the students, 49.7% were white, 35.8% black, 11.9% Hispanic, and 2.6% other. 51.8% of the students were female.

Approach: Five pairs of high schools were recruited. Each pair was matched on characteristics such as location (urban, inner ring suburb, or outer ring suburb), community socioeconomic status, and racial composition of the student body. In each pair, one school was randomly assigned to teach the Be Proud! Be Responsible! curriculum, including a booster session four to twelve months after the program ended, while the other school was assigned to teach a control health education curriculum, along with a control booster session. The program curriculum was taught by health education teachers and school nurses in health education classes to 9th and 10th grade students at urban and suburban high schools.

Data were collected at pre-test, immediately after the intervention, and at 4- and 12-month follow-ups, examining the outcomes of knowledge of condoms, HIV and other STDs, and general health, efficacy in terms of impulse control, condom negotiation skills, and condom technical skills, beliefs regarding the importance of condom use, how much condoms interfere, the protective quality of condoms, and the value of abstinence, perceived peer beliefs regarding the acceptability of sexual activity and the importance of condom use, and intentions to have sex and use condoms, and sexual behavior.

Results: The intervention had no impact on sexual initiation, frequency, or condom use. However, positive impacts were found on knowledge of STDs and condom use. Improvements were also found on impulse control, condom negotiation skills, condom technical skills, condom use beliefs, perceived peer beliefs, and intentions to have sex and use a condom at post-test. However, these impacts dissipated. Improvements in condom negotiation skills, condom technical skills, and condom use beliefs were significant at the four-month follow-up, but not at twelve month follow-up. Among students who were sexually inexperienced at baseline, those assigned to the program were more likely than the control group to have talked to a health professional about a sex-related matter at the four month follow-up.

Analysis by subgroup revealed that males in the intervention schools had higher impulse control, condom negotiation skills, and condom technical skills at post-test compared with those in the control schools, and the difference in condom negotiation skills remained through the twelve month follow-up. In contrast, there were no differences for females in terms of impulse control and condom negotiation skills, and the difference in condom technical skills were only maintained through the four month follow-up. Females in the intervention schools had lower intentions to have sex compared with those in the control schools, which was not true for males.

Subgroup analyses also demonstrated more consistent and sustained results among students at suburban intervention schools, with an increase in knowledge of STDs and condoms through twelve month follow-up and an increase in condom negotiation and condom technical skills through four month follow-up, while improvements found at post-test for students at urban schools, were not maintained at follow-up. Interestingly, students at urban intervention schools were more likely than students at urban control schools to believe that condoms interfere at four and twelve month follow ups, although not at post-test, and were significantly less likely to think that using condoms is important at twelve month follow-up. Impacts on rural schools were not reported.

Analysis by race revealed an increase in knowledge of condoms and STDs for both white and black students. However, the increase in knowledge of STDs was maintained through twelve month follow-up only for black students, while the increase in knowledge of condoms was maintained through four month follow-up for black students and through twelve month follow-up for white students. White students had improvements in condom negotiation and condom technical skills through four month follow-up and an increase in the belief that condoms protect against STDs at post-test, while black students had an increase in impulse control at post-test.

Evaluated population: A total of 86 community based organizations (CBOs), 22 from Philadelphia and 64 from New Jersey, were enrolled to give the intervention. At these CBOs, 3,445 adolescents received the intervention, but only 1,707 were included in the sample selected for follow-up surveys. The sample had an average of 14.8 years, was 56 percent female, and 90 percent Black/African American.

Approach: All CBOs implemented either the Be Proud! Be Responsible! intervention or the control intervention, a health-promotion intervention that focused on reducing behaviors linked to risk for heart disease, hypertension, lung disease, and cancer. Both the Be Proud! Be Responsible intervention and the control health-promotion intervention were implemented in one of three ways: 1) the manual-only condition where the facilitators received the intervention packet but no training, 2) the standard-training condition where facilitators received the intervention packet and a 2-day training, or 3) the enhanced-training condition where the facilitators received the intervention packet, a 2-day training, and practiced implementing the intervention with a group of adolescents. Each CBO implemented six intervention groups, and three of these were randomly selected for follow-up. Participants were randomly assigned to one of these interventions.

Both the Be Proud! Be Responsible! and the control health promotion intervention consisted of six, 50-minute modules delivered in two sessions of three modules each. Participants completed measures of sexual behaviors before the intervention and 3, 6, and 12 months after the intervention.

Results: A significantly greater percentage of participants in the Be Proud! Be Responsible! intervention reported consistent condom use over the three follow-up assessments when controlling for sexual experience at baseline, gender, age group, and race. Over the three follow ups, participants in the Be Proud! Be Responsible! intervention reported a greater proportion of condom-protected intercourse acts than participants in the control health-promotion intervention. Also, participants in the Be Proud! Be Responsible! intervention reported using condoms more frequently and were more likely to have used a condom in their most recent intercourse act than those in the control health-promotion intervention. A significant difference was found across age groups, such that intervention increased consistent condom use significantly more in older adolescents (17 to 18 years old) than younger ones (13 to 14 years old).

No differences were found between the HIV/STD intervention participants and the health-promotion intervention participants in regards to frequency of intercourse. In addition, the intensity of the facilitator training had no impact on the effectiveness of the intervention. The participants’ gender and race also had no impact on the effectiveness of the interaction.